Provider Demographics
NPI:1558143149
Name:BUSHONG, HOLLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BUSHONG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LADOGA
Mailing Address - State:IN
Mailing Address - Zip Code:47954-7046
Mailing Address - Country:US
Mailing Address - Phone:765-946-3331
Mailing Address - Fax:877-558-9529
Practice Address - Street 1:300 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:LADOGA
Practice Address - State:IN
Practice Address - Zip Code:47954-7046
Practice Address - Country:US
Practice Address - Phone:765-946-3331
Practice Address - Fax:877-558-9529
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014493A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily